Carotid endarterectomy surgery is the current standard for opening blocked neck arteries. In this procedure surgeons open the artery and surgically remove the hard, fatty build-up called plaque that is narrowing the artery. Once the material is removed the artery is sewn back together. This procedure requires at least an overnight stay in the hospital, one to two weeks recovery and wound healing time.
Aiming to improve patient comfort and minimize hospital costs, researchers studied the safety of outpatient carotid artery stenting. Patients who undergo ambulatory stenting don’t require anesthesia and can be up and walking within three to four hours. Getting patients out of bed and moving soon after the procedure also reduces the risk for complications such as low blood pressure or slow heart rate, says interventional cardiologist Nadim Al-Mubarak, M.D., of Lenox Hill Heart and Vascular Institute of New York.
Carotid artery stenting is very similar to coronary artery stenting, which is used to restore blood flow in the heart. In both procedures a catheter carrying the stent, a tiny wire mesh tube, is inserted into the femoral artery in the groin. From there it is carefully threaded to the site of the blockage. Once in place the stent is mechanically expanded so that it can serve as a scaffold to prop open the artery.
In the past, the catheter was removed manually two or three hours after the procedure and pressure was applied to the insertion site for 30 minutes. Patients were closely monitored in bed for six to eight hours to reduce the risk of bleeding from the site. “Now there is a new closure device, a suture that effectively closes the wound and reduces the risk of bleeding,” says Al-Mubarak. The suture is made of absorbable material and doesn’t require removal after healing.
In the new study, 98 ambulatory carotid artery stenting procedures were performed in 92 patients whose average age was 70. Twenty-eight percent were women.
Most of the patients, 72 percent, had no symptoms of stroke. In these asymptomatic patients the dangerous blockages in their neck arteries were detected during routine physical exams, often because doctors checking patients’ necks with stethoscopes detected telltale sounds called bruits, which are caused by the unsteady flow of blood in the arteries.
The remaining 28 percent of patients experienced symptoms within the three months before the procedure that included numbness on one side of the body, slurred speech and shaded vision, in which vision can be blacked out as if a shade is being drawn over the eye.
All patients had imaging studies such as ultrasound or magnetic resonance imaging to confirm the diagnosis of carotid artery stenosis or narrowing. In asymptomatic patients, carotid artery stenosis was treated if the obstruction was at least 80 percent of blood flow, while patients with symptoms were required to have a blockage of at least 60 percent. The average blockage was 78 percent, which was reduced to an average of 11 percent after stenting.
All of the patients were given two antiplatelet drugs (clopidogrel, once a day and aspirin, twice a day) for at least seven days before the procedure, or high doses of both drugs within 24 hours before the procedure.
The patients were observed for an average of six hours before hospital release. If they had no neurological problems, they were discharged the same day.
There were no strokes, deaths, or need for repeat procedures during one year of follow-up. Two patients required manual compression to stop bleeding because the suture failed to close the wound. One patient developed a complication at the insertion site six weeks after the procedure but he had no evidence of infection or bleeding.
Al-Mubarak says the experience suggests that outpatient carotid artery stenting is a safe option for most patients undergoing stenting and is equally good for both men and women.
He says that some centers may consider the procedure investigational and therefore will want to observe the patients for 24 hours. “But at Lenox Hill we have done the procedure on nearly 1,000 patients and we have rarely observed any complications beyond four hours after the procedure.
“All endarterectomy patients are also good candidates for stenting but not all stenting patients can be helped by endarterectomy,” he says. “For example, patients who already had endarterectomy are not optimal candidates for repeat surgery nor are patients who have had radiation treatments on the neck, which causes scarring of both skin and blood vessels.
Also if the blockage occurs high up in the brain or low in the neck, stenting is preferable to surgery.”
The co-authors of the study are Gary S. Roubin, M.D., Ph.D.; Jiri J. Vitek, M.D., Ph.D.; Gishel New, M.D.; and Sriram S. Iyer, M.D.
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